What’s the absolute minimum amount of exercise you need to protect your heart and metabolism? In this episode of The Movement Prescription, host Suzy sits down with the delightfully no-nonsense Professor Jason Gill from the University of Glasgow to throw out the "heroic" 100-day fitness trends and focus on what actually works for the next 1,000 days.

Whether you are a frontline healthcare worker looking for practical patient strategies or simply trying to navigate your own health journey, Jason delivers a refreshing, evidence-based reminder that "good enough is good enough" when it comes to diet and movement.

Key Takeaways From This Episode:

• The Two-Stage Weight Strategy: Why intensive dietary changes (or tools like GLP-1s) excel at initial weight loss, while physical activity acts as the ultimate anchor for long-term weight maintenance.
• Frequency Over Intensity: Why moving at least every other day matters more for blood sugar and metabolic health than a single grueling weekend workout.
• The 15-Minute Strength Secret: How doing just one or two brief resistance sessions a week—focusing on large muscle groups and pushing close to failure—unlocks up to 80% of the total health benefits.
• Stop Shielding Older Adults: Why lifting light soup tins doesn't cut it for seniors, and why progressive, safe heavy lifting is required to protect independent living.
• "Beautiful or Useful" Habits: How to make exercise stick for decades by ensuring it is either socially rewarding (beautiful) or seamlessly built into your daily routine (useful).

Episode Highlight: "The difference between doing something and doing something ideally might be 10%, whereas you get from 0 to 80% just from doing something. I'm interested in getting people from 0 to 80%." — Prof. Jason Gill

Intro and Outro: Hello, and welcome to this episode of the Movement Prescription podcast,

Intro and Outro: where I interview Professor Jason Gill.

Intro and Outro: He's a professor of cardiometabolic health at the University of Glasgow,

Intro and Outro: and he leads a multidisciplinary research group investigating the prevention

Intro and Outro: and management of vascular and metabolic diseases, including obesity and type 2 diabetes.

Intro and Outro: Today, we cover all sorts of topics. He's absolutely no-nonsense.

Intro and Outro: I think my favourite line from Jason is how little can we get away with?

Intro and Outro: Listen in to hear more.

Suzy: So Jason, thank you so much for coming along today to chat to me about physical

Suzy: activity and metabolic health.

Suzy: I'm here today with Professor Jason Gill, who is a professor of cardiometabolic

Suzy: health from the University of Glasgow. Jason, thank you so much.

Jason: Thank you, Susie. I'm delighted to be here.

Suzy: So, I'm actually just going to start with a very simple question,

Suzy: Jason, because some people may not be that familiar with cardiometabolic health

Suzy: as a concept. It's a pretty emerging specialty.

Suzy: Could you tell us a little bit about that and about yourself?

Jason: So thank you, Susie. So cardiometabolic health, I like to think of it as the

Jason: things which influence your risk of developing cardiometabolic disease.

Jason: So heart disease and diabetes principally, but also chronic kidney disease and

Jason: all sorts of diseases like that.

Jason: And metabolic health is essentially how good your body is at maintaining homeostasis.

Jason: So we look at things like your glucose concentrations, your insulin concentrations,

Jason: your lipid levels, your blood pressure.

Jason: And the idea is these are all in sort of normal ranges and this reduces your

Jason: risk of developing these diseases.

Jason: But also the effect of perturbations on these is a little bit less.

Jason: So if you have good metabolic health, what happens when you eat a meal which

Jason: contains fat and carbohydrate is you get a smaller spike in your blood sugar,

Jason: you get a smaller spike in insulin, you get a smaller spike in your triglycerides.

Jason: And so your body is just better able to cope with all the stresses that it's

Jason: facing in everyday life.

Suzy: Brilliant. Excellent. And tell me, Jason, how did you end up being a professor

Suzy: in cardiometabolic health?

Suzy: Because it's probably not a normal pathway for doctors to end up there.

Suzy: So tell us a little bit about that.

Jason: So I'm a scientist. I'm a PhD doctor, not a medical doctor.

Jason: I did my first degree at Loughborough University, and it was a joint honours degree in physics.

Jason: And and sports science um i

Jason: was a reasonably good triathlete when i was

Jason: younger um and i was interested in sort of things to

Jason: make people run faster and things like that and then during my my degree i became

Jason: more interested in the um effects of physical activity on health for everybody

Jason: that's not that's not trying to be an elite athlete so i i did an msc in sports

Jason: science So my PhD was looking at exercise and lipoprotein metabolism.

Jason: So principally how exercise influenced the way that your body handled fat in food.

Jason: I then came to Glasgow about 26 years ago to start a postdoc looking at the

Jason: effects of monounsaturated fats,

Jason: so olive oil type fats on lipoprotein metabolism.

Jason: We did some studies looking at lipoprotein kinetics. And then basically I stayed

Jason: for the next quarter century and I got various promotions through the system

Jason: and I've ended up where I am today. So my work now is pretty broad.

Jason: I do work on epidemiology, trying to understand how factors such as diet and

Jason: physical activity and obesity and ethnicity influence health.

Jason: I do work to try and understand the biological mechanisms, so what is it that

Jason: exercise or diet does to the body which influences health? and also work on intervention.

Jason: So how can we support people to make changes which they might be able to sustainably

Jason: do to change their health?

Jason: And I'm very interested in what works in the real world. So I'm interested in

Jason: what's good enough and what works and which is a slightly different question

Jason: from say somebody tried to optimise their performance to run a marathon or win a medal.

Jason: So I'm interested in what works for most people in the population.

Suzy: This is absolute music to my ears and i guess for many people who hopefully

Suzy: will be tuning into to the podcast you know healthcare workers who are trying

Suzy: to do this in their day-to-day,

Suzy: but you're giving us the evidence base behind that but a very practical real

Suzy: world evidence base you are a prolific researcher i see that from your bio that

Suzy: you sent me that you've published over 200 peer-reviewed papers and you've given

Suzy: us given this idea of the breadth of those papers.

Suzy: And you've contributed to loads of the guidelines, UK ones, signed guidelines, NICE guidelines.

Suzy: So, you know, really good to know that all of that sort of practical background is going into those.

Suzy: Because there is often that sort of implementation gap.

Jason: Hmm. Yeah. So what's, what's really interesting is we probably broadly know what we should be doing.

Jason: Um, the challenge is it's hard to do it in real life.

Jason: Um, so what's the word? It's, um, it's simple, but not easy.

Jason: Or is it easy, but not simple.

Jason: I can't remember. It's one of those two way rounds, but basically what to do

Jason: is fairly straightforward,

Jason: but doing it in the real, in the real world is really

Jason: really hard so i'm interested in finding um

Jason: out what people need

Jason: to do and i'm kind of interested in the question that a lot of

Jason: people ask me about is what's how little can you get away with because for

Jason: most people um what you

Jason: eat and how active you are isn't the number one priority in

Jason: your life and it's often for

Jason: people who isn't the number one priority that is probably

Jason: the most important for um so the question is

Jason: what is it that we can do to try and get

Jason: most of the way there in a way that's sustainable

Jason: and fits in with people's real lives and

Jason: and a key challenge is things that people are able to do for years

Jason: to decades um so so one of the things is

Jason: you sometimes see this idea that people need to do a hundred

Jason: day plan right so so i'm more interested in thousand

Jason: day plans so so what are we able to do for for a long period of time that's

Jason: sustainable because to get most of the benefits it's something you have to keep

Jason: doing over and over and over again and it's not just a um a short-term thing

Jason: to lose some weight for summer or something like that it's something that we

Jason: need to keep doing for a long long time so.

Suzy: There's no space for heroics here.

Jason: I think we have to do things that people are able to keep doing.

Jason: I mean, there's maybe something interesting here.

Jason: If we take weight loss as an example.

Jason: So I'd argue it's relatively straightforward to get people to lose weight.

Jason: I know it's hard, but over three months, most people can lose some weight.

Jason: The challenge is most people don't sustain the weight loss for two or five years.

Jason: Some people do, but most people don't. um so

Jason: it's a long-term thing that that's that's a challenge but

Jason: one of the things we can think about is the process that you need

Jason: to get the weight off is not

Jason: necessarily the same thing you need to do to keep it off so

Jason: when you say there's no no need for heroics sometimes it can

Jason: it can be really helpful to go in hard initially

Jason: and then transition to something that's more sustainable over

Jason: time so an example is um there was

Jason: a study called the direct study which was done at the

Jason: university of glasgow and university newcastle so it's led by professor mike

Jason: lean and professor roy taylor and what that did is it took people type 2 diabetes

Jason: and essentially gave them what they call a total diet replacement diets they're

Jason: four 200 calorie shakes a day which is nutritionally complete for between three

Jason: and five months and the idea is they lose between.

Jason: 10 and 15 kilograms of body weight and then

Jason: they have a food reintroduction phase to kind of keep that weight

Jason: off and what it found is about 46 percent

Jason: of people at one year um achieved diabetes

Jason: remission so they had their blood glucose levels not in the

Jason: diabetes range and uh it was

Jason: about 35 percent at two years but the key thing here

Jason: was there was this initial hitting people hard doing something that was quite

Jason: uh intensive and then transitioning into the longer term thing so i think this

Jason: two-stage model of you might want to do something quite hard initially and then

Jason: transition to something keep

Jason: it up it is is it is an approach i think works for at least some people.

Suzy: That's really interesting, actually, because, you know, the British Society

Suzy: of Lifestyle Medicine really championed this one change.

Suzy: And I guess that's what often is doable within the consulting room.

Suzy: You need that support and you need these big pathways and programs.

Suzy: In Scotland, we still have Counterweight Plus, which is based on that direct trial.

Suzy: And they're just about to do this. Obviously, you know this because you work

Suzy: in Glasgow, but this is for all of our listeners across the UK.

Suzy: They're just about to do the digital version of that.

Suzy: Actually, whilst we're on this subject, I wonder, have you been involved in

Suzy: research in providing these sorts of pathways digitally?

Suzy: Just thinking about that accessibility and X scale and all of that.

Jason: So, CountsWay is being delivered digitally as well.

Jason: It's not something that I'm directly involved with.

Jason: I am working with CountsWay on another project that is going to come forward

Jason: looking at delivering GLP-1 treatment in primary care to see whether we can

Jason: actually help prevent conditions happening in the future.

Jason: So that program is going to be a combination of a GLP-1 plus a digital support

Jason: behavioral package that we're working with Councilweight to deliver.

Jason: That's maybe something we can touch further in the future.

Jason: But I think one of the key things here is We've now, in terms of body weight change,

Jason: a range of options um which are greater than we had before and i think that

Jason: might make things um open up the range of possibilities going forward what.

Suzy: What are you thinking there specifically.

Jason: So i think glp1s have changed

Jason: the game and i think it'll be one of these things

Jason: that can be before glp1s and after glp1s um

Jason: what what we've got what we've got at them um in

Jason: in the past was we were able to achieve maybe 10 to

Jason: 15 kilograms of weight loss when people worked really really hard at

Jason: it um and some people were able to do

Jason: that but many people weren't able to do that and

Jason: keeping weight off was was really hard and a lot of it is because

Jason: you've got all these biological drives to try and eat more food when you when

Jason: you when you're at negative energy balance and and and what the glp ones do

Jason: is provide you support to take away those those food cravings um one one analogy

Jason: i like to use is it's is maybe a little bit like nicotine replacement therapy.

Jason: So when someone's trying to stop smoking it's it's

Jason: really it's really hard but what nicotine replacement therapy

Jason: does is it um it helps

Jason: damp down the cravings and stuff so you can put in place

Jason: the behavior change is more easily that you might

Jason: be able to sustain and then eventually you might be able to come off it so so

Jason: one way of thinking about glp1s is they

Jason: might they might they might do that that's not necessarily the way they're always being used

Jason: now but they can actually provide this this scaffolding to help do a lot of

Jason: the other things and make them easier to do and then in time some people might

Jason: be able to wean themselves off the glp one some people won't be able to um but

Jason: but um that might be a model that we can use going forward so so i think,

Jason: we need to use all the tools we have available to us and i think something with

Jason: physical activity which I've been working on for three decades now,

Jason: I think the focus on what we're trying to do with physical activity might change a little bit.

Jason: Because in the past we considered it

Jason: for a number of things including can it help with weight

Jason: loss right um now i think we focus on a lot of the other benefits so um improving

Jason: um uh fitness and and muscular strength provide additional benefits over and

Jason: above effects on weight so i think if we take all the tools we have have available um that.

Jason: Increases the options i think i think we're in a much better position

Jason: now than we were in 10 years ago 10 years ago

Jason: when we didn't have uh so many so

Jason: many options on the table when we wanted to try and help people live healthier

Jason: lives but also to enable them to do things that they want to do so if you are

Jason: um a bit fitter and a little bit lighter um everyday activities become a little easier.

Jason: And so the quality of life changes might be substantial.

Jason: And now we've got an opportunity to help people to improve their quality of life.

Suzy: Because often there's that conversation about, well, actually,

Suzy: physical activity doesn't lead to weight loss per se.

Suzy: I've heard you say that a couple of times before. For people who maybe aren't

Suzy: clear on that, could you just sort of tell us a bit more about why that is?

Jason: So physical activity on its own

Jason: probably leads to modest weight loss so in the order of

Jason: a couple of kilograms and and and one

Jason: of the reasons there's a couple of reasons for that one is unless you

Jason: are very very fit your ability

Jason: to burn calories doing physical activity is somewhat limited so if you are if

Jason: you walk for 30 minutes you probably are expending two to three hundred calories

Jason: right um and if you think about the number of calories you need to burn to lose

Jason: a kilogram it's in the order of i think it's seven thousand seven hundred calories

Jason: and a kilogram of adipose tissue.

Jason: So it's a lot of 30-minute walks to do that.

Jason: There's also some feedback mechanisms in that you might feel hungrier,

Jason: so you might eat a little bit more food.

Jason: So physical activity on its own, if you're using it to try and lose weight,

Jason: is not that effective for most people.

Jason: Some people are able to do lots of physical activity and lose lots of weight,

Jason: but for most people it probably isn't.

Jason: And the evidence is diet plus physical activity is better than either on their own.

Jason: Where physical activity does come into its own is in the weight loss maintenance

Jason: phase of keeping weight off.

Jason: And there is now reasonable evidence that if you have increased physical activity

Jason: in the weight loss maintenance phase, you're better at keeping the weight off.

Jason: So again, we talked about this two-stage process.

Jason: For the initial weight loss, eating less food, either through a diet or using

Jason: a GLP-1 drug to try and make you feel less hungry so you eat less food,

Jason: is probably the dominant mechanism.

Jason: When you want to keep weight off, physical activity becomes really important.

Jason: And one thing that we should maybe reflect on is that if somebody is very,

Jason: very heavy, say they weigh 130 kilograms, doing physical activity will feel hard.

Jason: And it might feel easier if they've lost some weight.

Jason: So I think there's an argument for trying to get weight off.

Jason: Predominantly using diet initially and then

Jason: bringing the physical activity in a little bit later when

Jason: people are able to do it they might enjoy it more because the key thing is you

Jason: kind of you you do things that you that you enjoy and if you if your first experience

Jason: of physical activity this is really really hard you might you might be turned

Jason: off about it but if you're a little bit lighter your body moves a little bit

Jason: easier you might be more receptive to it later on so i I think we should be

Jason: open. I think we should be open to that.

Jason: The one other thing I'd like to add, maybe before we move on,

Jason: is I think it's important to consider there's two different forms of activity we're interested in.

Jason: One is the aerobic activity. So walking, running, cycling, all these things

Jason: that burn lots of calories.

Jason: And the other is resistance exercise or muscle strengthening activity.

Jason: And often when we think about activity, we tend to think about the aerobic type activities.

Jason: And resistance activities are forgotten. And there's quite a lot of evidence

Jason: now that low strength is strongly related to a range of adverse health outcomes.

Jason: People that do muscle strength activities have

Jason: improved outcomes in terms of cardiovascular disease

Jason: diabetes and all-cause mortality and

Jason: doing a combination of aerobic and resistance exercise seems to be better for

Jason: things like HbA1c levels in people with diabetes so I think doing resistance

Jason: exercise early on can be important not least because it can help you hold on

Jason: to lean mass Because when you lose weight, by whatever means,

Jason: you'll lose a combination of lean mass and fat mass.

Jason: Some of this is appropriate. If you're smaller, you don't need to have as much lean mass to support it.

Jason: But there is a possibility that if you do some resistance exercise while you're losing weight...

Jason: You can change the mix of weight that you lose. So it's more fat mass and less

Jason: lean mass. And I think that's important.

Jason: The dose of resistance exercise you need is probably smaller than you think.

Jason: Probably 15 minutes a couple of times a week gets you most of the way there.

Jason: So you don't need to do huge sessions at the gym. You need to do more than zero.

Jason: But the amount more than zero might be less than people think.

Suzy: That's really interesting and probably very accessible. so you know should should

Suzy: all glp1 medications or people going on to a weight loss diet of any description

Suzy: come with the instructions that you should be pairing this with resistance training

Suzy: to begin with do you think.

Jason: So i think there's a benefit of doing that and i think we're maybe not

Jason: doing it as much as we could do i think

Jason: a challenge is with resistance

Jason: exercise most people think about going to

Jason: the gym which can be quite a scary

Jason: place for a lot of people um and it's

Jason: very very easy not to go to the gym so i

Jason: think we we are developing things and other people are as

Jason: well about home based resistance programs using body

Jason: weight and resistance bands so i think so i think doing resistance

Jason: activity a couple of times a week is very very helpful i think we need to provide

Jason: people with evidence-based programs which they can do in their home and I think

Jason: if we do that then that would be a valuable thing to add to most people's weight

Jason: loss programs but also for general health I think everybody should be doing resistance exercise.

Suzy: That's brilliant what what what is that to look like do you know Jason?

Jason: It's quite interesting if you look if you look on various online things you

Jason: see people talking about their particular resistance exercise program that's

Jason: special and gives you bigger benefits and other things, but I think it's actually quite simple.

Jason: We need to do activities, resistance exercises to strengthen our lower body and our upper body.

Jason: And broadly, you can think about you've got the front of your upper body and

Jason: the back of your upper body.

Jason: So the way that you get the front of your upper body is to do what you call a push exercise.

Jason: So something like a chest press

Jason: or a shoulder press where you push vertically. So a couple of pushes.

Jason: You can probably do a minimal thing and just do one push.

Jason: Some sort of pull which gets your back so you can do a

Jason: vertical pull so a pull up if you're able to do it most people can't but

Jason: you can do a horizontal pull quite easily so it's like it's it's

Jason: called a rowing exercise one way you can do it is by looping a resistance band

Jason: around your feet have your feet in front of you and pulling back so a

Jason: pull and then two lower body exercises one

Jason: to get the front of your legs and one to get the back of your legs so the

Jason: one to get your front of your legs is a squat or a

Jason: variation on a squat so one way a squat essentially

Jason: getting out of a chair without using your arms that's a

Jason: squat you can do it with a weight if you're a bit

Jason: stronger and and then a hinge motion

Jason: which is where you sort of have your your body leaning forward

Jason: you pull it back up so the classic hinge is a deadlift it doesn't need to be

Jason: that but that gets your your the backs of your legs so if you can kind of do

Jason: those four exercises and sometimes i would say do do two pushes a horizontal

Jason: push and a vertical push horizontal pull vertical pull and so six exercises is probably enough.

Jason: The key thing here is you get about 70% of the benefit of doing four sessions

Jason: a week from one session a week.

Jason: So going from 0 to 0, no sorry, from 0 to 1 gets you most of the way there.

Jason: So one session a week is great.

Jason: Two sessions a week gets you almost all the way there. And the added benefit

Jason: of doing three or four is quite minimal.

Jason: The other thing is that when we think about the sets of exercise,

Jason: people say we'll use three sets of 10 or whatever,

Jason: you get most of the benefit from set one so you

Jason: only actually really need to get most

Jason: of the benefit one set of the exercise the key thing is to

Jason: do the exercise until close to

Jason: the point of failure it doesn't actually need to be failure but

Jason: that's quite an easy sort of coaching point to tell someone it's easy to prescribe

Jason: it say basically if you're doing say a chest press or a bench no sorry a press-up

Jason: type exercise which you can do on your knees or against the wall if you're not

Jason: strong enough to do it on your feet you do it until you can't do another one right that's it,

Jason: once you get a resistance band around your legs and

Jason: then you pull that way until you can't do it anymore you do

Jason: some variation of a squat you can do it um

Jason: with uh with just body weight you can do it standing up from a chair you can

Jason: do it with a jump in between to make it harder if you're quite strong you can

Jason: you can put a weight on but do that once until your legs feel they can't do

Jason: anything else um a hinge you can do by sort of holding some weights in your

Jason: hand and sort of standing up or you can do it with a band around your legs.

Jason: Couple times a week one set to the point where you basically

Jason: feel that you'd struggle to do another rep that gets

Jason: you most of the way there so i think i think doing something that's very simple that

Jason: you're able to do over and over and over and over again um is

Jason: what most people should be doing and in in some ways i'm not fussed about the

Jason: nuance because the difference between doing something and doing something ideally

Jason: might be 10 whereas you get from 0 to 80 just from doing something so i'm interested

Jason: in getting people from 0 to 80 brilliant.

Suzy: And that's so practical as well i don't think i

Suzy: would have necessarily um even having heard you speak a

Suzy: couple of times before realized actually the importance of introducing resistance

Suzy: training early before cardiovascular because i guess as someone who enjoys cardiovascular

Suzy: exercise i love walking i love running that comes through when you're enthusiastic

Suzy: about something but actually you need the science to back it up and you've just

Suzy: given us that the the understanding of that science as well so that's really helpful.

Jason: Yeah so in the aerobic activity is

Jason: absolutely important and we should be doing it and

Jason: there's lots and lots of evidence to show that it improves some health outcomes

Jason: um my subtle point is if you're very heavy and you're trying to lose weight

Jason: it's just the sequencing of the of the two um and and and not doing it initially

Jason: when you find it hard uh might be an option that works for some people.

Suzy: So that's you've given us actually quite a lot You've covered a lot of the questions

Suzy: that I have planned out for later.

Suzy: So whilst we're thinking about what you need to do, when you were talking last

Suzy: time, you were talking about the beneficial effects and how long they last for

Suzy: and why it's important to do little and often.

Suzy: Could you tell us a little bit more about that and the evidence behind it?

Jason: Yes. So one of the things that we see with a lot of the benefits of activity.

Jason: So benefits like reductions in blood pressure or improving insulin sensitivity,

Jason: which is the ability of insulin, your body to sense insulin to control your

Jason: blood sugar levels or the changes in the triglyceride levels in your bloodstream,

Jason: is you get this acute benefit after you've done an exercise session,

Jason: which lasts maybe between two or three days.

Jason: So the idea is if you do an exercise session you're in this beneficial metabolic period for

Jason: a couple of days and then it kind of dissipates and

Jason: the idea is if you can do activity relatively frequently probably

Jason: at least every other day you're constantly in this

Jason: favorable metabolic state and a

Jason: large proportion of the benefit of being a regular somebody's regularly

Jason: active is from this repeated acute effect

Jason: rather than necessarily a long-term training

Jason: adaptation there are bits of long-term training adaptation but most

Jason: of the benefit you get is from the last session you do and if

Jason: you look at evidence for say people with type

Jason: 2 diabetes looking at the benefits of of of

Jason: activity on hba1c you find the

Jason: biggest determinant of the effectiveness of

Jason: a program is how frequently you do the activity so frequency is probably the

Jason: most important variable we need to we need to think about when particularly

Jason: with uh people who already have um maybe impaired metabolic health is is frequency

Jason: of activities important i'd say at least every other day.

Suzy: Every other day okay that's um trying to keep our patients going how how can

Suzy: we do that how can we motivate people jason is there evidence behind the best way to motivate people.

Jason: Yes so we we've done,

Jason: We've done some work to try and see how to get people to show up and keep showing up.

Jason: And one of the studies we did a number of years ago was a study called Eurofit.

Jason: So this was a study where we looked at men because men are a hard to reach group.

Jason: If a healthcare professional tells a man that they need to lose weight or be

Jason: more active, they're generally less receptive to hearing that message than a woman.

Jason: So what we did is we leveraged the fact that many men like their professional

Jason: football club they support.

Jason: And so we went to the football clubs and we got them

Jason: to advertise to their middle-aged male fans and we got them to to do a program

Jason: which was increasing physical activity and changing diet but what we did is

Jason: we trained the club coaches like the youth team coaches to deliver the intervention

Jason: to the men and this was clubs you've heard of so manchester city arsenal,

Jason: everton benfica porto psv eindhoven clubs

Jason: clubs like that and and it was it was really effective we did a study in

Jason: about 1100 men they lost a bit of weight they increased their

Jason: physical activity and it worked really well so the key thing here is

Jason: to do something people are prepared to do and what men liked was

Jason: showing up with other men and having the banter that you get you get you get

Jason: in these sessions and people and people showing up and we're we're having conversations

Jason: now with um a group called walking football and there's an organization that

Jason: does walking football walking football i think is it's really good because it's

Jason: something that um you can do as you get older and.

Jason: Your knees give up and you can't maybe do normal football. It's something that keeps people active.

Jason: So I think that's two things broadly you need to do. So,

Jason: William Morris said in your house, you should only have things that are useful

Jason: or you think are beautiful.

Jason: And I think we can think of the same thing with physical activity.

Jason: So we want it to be beautiful in that you want to do it. You're doing it for

Jason: a reason other than your health.

Jason: So a man that shows up to play five-a-side football, primary reason they're

Jason: doing it is not because it's for their health. It's because they enjoy it.

Jason: They meet with their mates.

Jason: They get the banter and all those things. So if you want people to keep doing

Jason: things, you need to do things that people enjoy.

Jason: So it's kind of finding something that you want to do for other reasons than your health.

Jason: The other thing that we can do is make it useful. So it's doing physical activity

Jason: in a way that's embedded into your life.

Jason: So one of the key things you see is if you ever go to Amsterdam,

Jason: is everyone rides their bike.

Jason: They don't ride their bike to get exercise. They ride their bike because that's

Jason: just the easiest way to get from A to B.

Jason: It's just that that's what everyone does. So it's a very useful thing.

Jason: And there's some evidence that suggests that life expectancy in the Netherlands

Jason: is 0.6 years higher because everyone cycles everywhere.

Jason: And so it actually has a huge effect on on population

Jason: health and we're doing some work now doing a

Jason: developing an interval we're doing a randomized control trial of

Jason: an intervention to try and encourage people to cycle more uh for

Jason: for commuting and the idea is that if people do

Jason: that they're getting it in so they whether it's

Jason: raining or whatever they they need to get to work

Jason: so they're more likely to do it so so i think broadly thinking

Jason: about one of those two things and I think going to the gym just because you

Jason: think it's good for you is probably not a way to keep people active I enjoy

Jason: going to the gym I go I get something else out of it so I so I enjoy doing it

Jason: but that but I'm not most people um and so just telling people just go to the gym,

Jason: probably only works if there's somebody that maybe wants to go to the gym but

Jason: there's other ways that they can be active and.

Suzy: I know you've done research in in other you use the the word hard to reach communities

Suzy: I think there's um another term that we're supposed to use um but other communities

Suzy: that are more difficult to engage um can you can you give us some examples of

Suzy: other types of of groups that you've researched into.

Jason: So we've we've done some work looking at ethnicity and health is that is that

Jason: what you're getting so so so we we've done a quite a lot of working at um trying

Jason: to understand risk of diabetes in south asians so if you are of south asian ethnic origin,

Jason: you've got about three to four times the risk of diabetes compared to somebody

Jason: who's of white European origin.

Jason: And we've done some work to try and work out why that's the case.

Jason: And we show that on average, South Asians have lower cardiorespiratory fitness.

Jason: So cardiorespiratory fitness is your ability to use oxygen to do work.

Jason: So somebody that's able to run fast over 10K has a high level of fitness.

Jason: And what our data suggests is people who are South Asian might need to do more

Jason: physical activity to get to the same level of fitness.

Jason: We also show that South Asians are a little bit less strong,

Jason: so they might need to do more resistance exercise. and that when they gain weight,

Jason: there's a bigger adverse consequence.

Jason: So there are some biological differences in what might be optimal in different groups.

Jason: And evidence shows that.

Jason: The interventions that we have to try and reduce diabetes, which typically involve

Jason: taking people who have higher glucose levels than normal, but not high enough to diagnose diabetes.

Jason: We call it pre-diabetes or impaired glucose regulation. If you give these people

Jason: an intervention where you get them to increase their physical activity and lose

Jason: a bit of weight, you reduce the number of people that end up developing diabetes.

Jason: And what we find in South Asian populations is those interventions work but

Jason: they work a little bit less well than they do in in other ethnic groups and

Jason: one of the things we're trying to do is explore why and that's important because.

Jason: The reason why something doesn't work is important for understanding what to

Jason: do next so so one reason it might not work is biologically the same intervention

Jason: has a different effect physiologically and if and if that's the problem what

Jason: you need to do is work out what the intervention might be and there might be

Jason: a different type of intervention.

Jason: The other reason something might not work is the intervention would work,

Jason: but people are less likely to engage because it's not appropriately tailored to them.

Jason: So, for example, you've got a diet intervention, and it's not using foods that

Jason: people typically eat if they come from South Asian countries,

Jason: right? So they kind of don't engage with it so much.

Jason: And if that's the case, then what you need to do is do the same intervention,

Jason: but work out a way of culturally making it culturally more appropriate.

Jason: So understanding which of those two is the case is really, really important.

Jason: There is some evidence that it's probably a bit of both. And we probably need

Jason: to do some work to both make things more culturally appropriate,

Jason: but also understand what those interventions might be.

Jason: Scomist study which is the glp so it's a scotland cardiometabolic

Jason: intervention study which we're designing now uh looking at using glp1 drugs

Jason: in primary care we are deliberately targeting people in lower ses communities

Jason: because these are the people that have less access and so what we're hoping

Jason: to do is by targeting people in lower ses communities we might reduce health inequalities and,

Jason: as well as hopefully having bigger downstream effects on health service utilisation and events.

Jason: Because what you find is there's quite a big social gradient in terms of adverse health outcomes.

Jason: So we're targeting the people who have the most risk.

Jason: And also, these are the people who might have less access to the GLP-1 drugs privately.

Jason: So we're trying to address health inequalities in a range of different ways.

Suzy: And that study that you just mentioned there, how big is that going to be?

Jason: So we're in the research design phase at the moment, and we need to submit a

Jason: protocol sort of in September, and then hopefully if that gets approved, we go to the study.

Jason: So we will have, in the intervention arm, 2,500 people will be given GLP-1 drugs

Jason: over three years, and then we're going to follow up until six years,

Jason: and we'll have a control arm as well that won't have GLP-1. So it'll be relatively

Jason: big and relatively long.

Suzy: Yeah, it sounds like a fascinating trial going forward. So we shall watch this space with interest.

Suzy: That is a subject which is very close to my heart. I was just pulling together

Suzy: some information for a discussion with the Deep End group about lifestyle medicine in the Deep End.

Suzy: So I may quote you on that as things that are going on, if that's okay, Jason.

Jason: What are you going to say to your Deep End colleagues?

Suzy: What am I going to say? Well, my goodness, we've got 20 minutes.

Suzy: So my approach is that actually I

Suzy: am a GP working in a deep end practice and I think it's needed there more than

Suzy: anywhere else that unfortunately lifestyle medicine is whilst not a protected

Suzy: term can and it can sometimes be misrepresented it is this evidence-based clinical

Suzy: care that supports behavior change

Suzy: meeting the patient where they are focusing on the pillars of health,

Suzy: and then I think the most important thing is that we're meeting patients where they are,

Suzy: And we're making meaningful, shared decisions with them. We're not giving them

Suzy: lifestyle advice. We're not telling people what to do.

Suzy: We're working on their self-efficacy, all of these things that anyone who's

Suzy: heard me speak before will have heard me say all of those things.

Suzy: But that's what I'm really passionate about. So it's great to hear that there's

Suzy: sort of research that is focusing on the groups that we are working with day to day.

Jason: Can I ask you another question?

Suzy: Yeah.

Jason: So you have a relatively short time with each patient.

Suzy: Yeah.

Jason: Right and you're normally having to deal with something else as well as this,

Jason: So what advice can you give and support can you give in the three minutes that

Jason: you've got? What's the first thing that you do?

Suzy: Jason, you've just turned the tables on me. I thought I was interviewing you.

Suzy: The first thing, Jason, is it depends. It depends what the patient is.

Suzy: It depends on the context. It depends how well I know them.

Suzy: But usually the discussions I have with patients, number one, they always overrun.

Suzy: Anyone who knows me will know that I continue to have on my personal development

Suzy: plan that I will run to time next year.

Suzy: That is an ongoing piece of work.

Suzy: I think, Jason, it just depends on what the patient's after.

Suzy: But some of the most impactful conversations, the ones that you expect the least.

Suzy: So I will always seek permission to have a lifestyle discussion with people.

Suzy: And it's amazing, actually, it's often surprising the people who are the most

Suzy: invested in wanting to talk about what they can do for themselves,

Suzy: seeking advice, wanting to know where they can find out more information.

Suzy: And then it's about attaching people to the

Suzy: community assets that you have um i'm trying to think of an example for you

Suzy: i did actually do you know what i hope you won't mind uh and i'll keep it as

Suzy: anonymous as possible but i had a relatively young man in recently who's had

Suzy: a heart attack already um and he came in with a list of he's been saving them up for me typical,

Suzy: and he had a list of five things and i said just tell me what they all are and

Suzy: then we'll just see which one matters the most to you today and see what we can do.

Suzy: And actually what mattered most to him was that he wasn't sleeping.

Suzy: But by letting him talk about not being able to sleep, all these other issues,

Suzy: which crossed all the pillars of health, came out.

Suzy: And actually, by the end of the consultation, we'd spoken about priorities.

Suzy: We'd spoken about all the other factors, the overwhelming stress.

Suzy: He'd taken on too much. He had too many responsibilities.

Suzy: And I stopped him at one point. I was like, let me just ask you a question.

Suzy: Do you use your phone in bed at night?

Suzy: And he was like, yeah, I'm answering questions all the time.

Suzy: And I was like, right, okay, well, do you mind me saying that's probably where

Suzy: you need to start? And he was like, oh, yeah, that's where I need to start.

Suzy: And actually, if you can find one thing that you can work on with a patient, he actually stood up.

Suzy: He said, I think you were the right doctor for me to come and talk to you today.

Suzy: You're right. I didn't need another pill. I've got plenty of those already.

Suzy: I'm going to go away and have a think about what I need to do. so actually

Suzy: i didn't tell him anything apart from

Suzy: identified okay the major problem to the one of the your problem lists here

Suzy: you've got your phone on in bed at night that needs to stop and then let's start

Suzy: with everything else so it wasn't a physical activity focus to that consultation

Suzy: it was what matters to this patient and it's not always immediately clear sometimes

Suzy: you just need to let these things evolve.

Jason: Okay can i ask you two more questions um so um i'm turning the tables the first

Jason: is how common do you think what you did is do you think all your colleagues are doing the same thing.

Suzy: I think we all practice in very different ways it would have been very easy

Suzy: just to to comment on the dermatological things that he he started with in his

Suzy: list but i think a lot of gps do the lifestyle medicine approach without realizing it,

Suzy: It's good holistic care.

Jason: Okay. So my next question is, we do a bunch of research on lots of different things.

Jason: You as somebody on the front line, who's dealing with real people in the real world,

Jason: what are the key bits of evidence or things about effectiveness would be really

Jason: helpful for you so that you can, in your three minutes you have with somebody

Jason: to talk about this, do that more effectively?

Suzy: Oh, that's a good question. I suppose the things that I find the most useful

Suzy: are the things that I can use often.

Suzy: So one of my favorite, and again, I've mentioned this in many talks and many

Suzy: podcasts before, but one of my favorite infographics, because I love an infographic,

Suzy: I think a picture tells a thousand words, particularly for physical activity,

Suzy: is that World Health Organization dose response curve on physical activity.

Suzy: Because I'm often dealing with the red man in the corner who's sitting in his

Suzy: chair. and if I can get him to move a little bit more, that's where the biggest gains are going to be.

Suzy: And having something simple that I can use in just about any situation where

Suzy: that seems relevant, which is often, by the way, I can point to that and say,

Suzy: listen, this is what I'm interested in. This is where we could start.

Suzy: So I guess it's about having...

Suzy: Easy to use resources and i know moving medicine has just come out with some

Suzy: patient facing resources based on both condition um and and also um symptoms

Suzy: i don't know if you've had anything to do with that jason or aware of it but i've.

Jason: Seen some of the stuff i'm not involved with them.

Suzy: So that's the sort of thing that i can i can point a patient at but you know

Suzy: working in a pocket of deprivation not everyone has access to the internet um

Suzy: so sometimes it's about having posters for the waiting room.

Suzy: It's very basic where I work, but that's not necessarily relevant to anyone.

Suzy: I would love to hear from anyone who is listening from this who could answer

Suzy: that question. You've just put me on the spot there, Jason. I thought I was

Suzy: asking you all the questions.

Jason: Well, you can ask me some questions now.

Suzy: Was that what you were thinking I might say?

Jason: I don't know what you were going to say. I guess one of the things that we're

Jason: doing, so we can sometimes we do things that are really getting to niche detailed type things and,

Jason: they help and help with scientific understanding they help with biological mechanisms

Jason: but the broad messages about what we need to do are probably not going to change

Jason: based on that you might change some of the nuance but we know what the broad

Jason: messages are and i think that the challenge we have is to say,

Jason: I think you mentioned on the top, the implementation gap.

Jason: And I think the big challenge we have is long-term behaviour change,

Jason: not initiated behaviour change.

Jason: Initiating behaviour change is one set of problems and.

Jason: We've got solutions that work for at least some people there's kind of things

Jason: we need to do for people that they work i think where we've got the big challenge

Jason: is how to how to help people,

Jason: sustain behavior change in in the real lives which are busy and you have setbacks you might have,

Jason: because what you sometimes find is people are doing really really well until

Jason: something happens in their life and then they fall off the wagon and

Jason: then it's really really hard to get back on again and so

Jason: it's trying to work out how we actually help support people

Jason: over the long term and i think that's

Jason: the part of my

Jason: job that i'm most interested in just now um is

Jason: how we get how we can keep people in the real world sort of having a lifestyle

Jason: that's not perfect but good enough for for for a long period of time so i've

Jason: kind of uh good enough is good enough is kind of I don't think anyone needs to be optimal.

Jason: I think optimal is something that is not really worth achieving.

Jason: Most people are going to fail at that.

Jason: I think if we can get most people good enough, I'll be happy with that.

Suzy: And I suppose this is where doing face-to-face one-to-one medicine in small

Suzy: rooms can be frustrating because you're going against the grain often.

Suzy: You know, behavior change within a society that is encouraging us to sit still,

Suzy: it is not encouraging us to be active. It's not encouraging us to eat well or sleep well.

Suzy: That's the difficulty. And I guess, you know, lifestyle medicine as the BSLM

Suzy: tries to sort of bridge that gap between...

Suzy: Sort of front door medicine and public health and somewhere in the middle.

Suzy: It would be lovely if we could, you know, cause this wholesale cultural shift

Suzy: so that it, you know, we're not working against the grain all the time.

Suzy: I don't, I don't know how on earth we're going to achieve that.

Suzy: But, you know, the fact that there is a growing swell of people willing to practice

Suzy: this on the coalface, I think is so important.

Jason: Yeah, I think it's really important. And I think one of my favorite phrases

Jason: is both and so so we kind of need to do

Jason: that we we also need to try and see whether we can alter societal things and

Jason: pull pull pull those bigger levers as well and i think we need to lobby to make

Jason: those changes but i think we we can't just rely on the food system to change

Jason: and just wait for that to happen there's other things that we need to be doing

Jason: um in the interim as well so.

Suzy: We have done a whistle stop tour um and you've turned the tables on me,

Suzy: which I wasn't expecting.

Suzy: And I wonder whether you can, you

Suzy: know, you've sort of slightly moved us towards a bit of a call to action.

Suzy: So, you know, the people that this is generically aimed at is people in primary

Suzy: care who are trying to promote physical activity.

Suzy: You know, we're thinking about in the context of cardiometabolic health.

Suzy: So what would be your take home messages?

Suzy: I've written a few things down here that I've taken from you.

Suzy: And by the way, i frequently now quote you on that both and not either or i

Suzy: hope you don't mind but it's on just about it i.

Jason: Think i i i i i i will have stolen it from someone else as well so i don't have copyrights on the term.

Suzy: What do you think from your research point of view we should be focusing on

Suzy: from a cardiometabolic health point of view what are the little gains that we

Suzy: can do over and over again um do you think yeah.

Jason: So so so so i think the key thing is is is doing things over and over again

Jason: so so there's a couple of bits if you are heavier than you want to be,

Jason: I think considering weight loss and weight loss maintenance is two different

Jason: things, I think is important.

Jason: There's often discussion about, well, just do something sustainable and easy.

Jason: And this is one of the things where the evidence is probably the opposite of common sense.

Jason: So the biggest determinants of weight loss at one year is weight loss at one month.

Jason: So people that go in hard are better off at one year.

Jason: So I think going in hard initially and then moving into a cruise phase where

Jason: you do something else is probably important.

Jason: Things like the total diet replacement, the direct used and is at counterweight

Jason: plus, seems to work quite well.

Jason: And one of the reasons it works quite well is it takes all the choice and thought

Jason: out because you think about what am I going to eat next and I've got all these

Jason: things there. If you go, I've got the shape and that's it.

Jason: Right you don't need to think you mean it takes all that thought out so you

Jason: can basically get the weight off not think about food because you don't have any choice.

Jason: And then when you've got some weight off um keep keep going

Jason: and and i think one of the things that the counterweight dieticians do very

Jason: well is help that food reintroduction phase

Jason: actually how you how you do things going on so i think so

Jason: that works quite well so the the how you get

Jason: somewhere and what you do long term might might be different things

Jason: physical activity is important and i think it's important to recognize there's

Jason: two types of activity that we need to do broadly there's the aerobic type activity

Jason: and one way to do that is just to get a step counter everyone has a step counter

Jason: because your phone is a step counter now and everyone has one of those and and and try and

Jason: look at your baseline level of steps and gradually build it up so rule of thumb

Jason: is a thousand steps is about 10 minutes of walking right so if you can kind

Jason: of see wherever you are if you're sitting at 3,000 steps,

Jason: try and increase to 3,400 or 4,000 for a couple of weeks and see whether you can go further.

Jason: With the dose-response relationship, you mentioned this earlier,

Jason: is the steepest part is the first bit.

Jason: So wherever you're at, the first bit you do is going to give you the biggest

Jason: benefit and then you get diminishing returns.

Jason: With steps, a key point is we hear the number 10,000.

Jason: The number you need is probably much less than 10,000. It's probably 7,000 to

Jason: 8,000 and traught plateaus.

Jason: So you don't need to get to 10,000. So if you can hit 8,000.

Jason: Probably good enough on top of that do

Jason: some resistance type activities we

Jason: talked about it earlier on it doesn't need to be anything

Jason: fancy just major muscle groups um a

Jason: couple of times a week one set to close to failure get you

Jason: most of the way there the the other

Jason: thing that i want to say briefly and i was chatting to my dad about this yesterday it's

Jason: often with older people we are scared to give them the activity that would benefit

Jason: them so if you look at classes with older people they have sort of very very

Jason: light weights they do things that you don't but what what you need to do to

Jason: actually if you want to keep your capacity you need to keep pushing up to that barrier.

Jason: So I was saying to my dad, so you need to lift heavy weights,

Jason: not to get stronger, but to keep what you've got going forward.

Jason: And so the idea of people saying, oh, you're lifting bean tins,

Jason: that probably doesn't cut it for most people.

Jason: I remember doing something with my dad and we were trying to,

Jason: I was getting some weights to lift that. No, it's far too heavy. It's far too heavy.

Jason: And then it's like he was able to do eight reps. They go, no,

Jason: that's the weight you need.

Jason: And so i think one of the one of the challenges here really really important

Jason: challenge is the the the appropriate load for people is generally higher than

Jason: people think the appropriate load is,

Jason: and it's giving people confidence um to

Jason: say look this is the load you should and it's safe

Jason: it's fine right um you need to be going

Jason: using a weight that's relatively heavy for you so relatively

Jason: heavy for an 80 year old is very different from relatively heavy for

Jason: a 20 year old but doing something that that

Jason: isn't pushing you is probably

Jason: not going to be optimal so i think that's a that's a

Jason: key take-home message i think is maybe different from

Jason: almost uh the the popular conception of what we should be doing with all the

Jason: other so so things like chair based activities and things like that we we need

Jason: we need to be pushing people a little bit and and not being scared to push people

Jason: um We don't want 80-year-olds doing sort of maximal sprints,

Jason: but probably a little bit more than we are generally comfortable doing,

Jason: I think, would be a take-home message.

Suzy: Brilliant, Jason. Well, listen, I'm going to be thinking about what you said

Suzy: earlier on. Simple, but not easy. I think that might be the way around that it is.

Suzy: And the thousand-day plan, I love that. I may continue to quote you on that as well.

Suzy: Listen, thank you so much for giving us a whistle-stop tour and some really

Suzy: good practical advice. You know, how little can you get away with is the tagline,

Suzy: I think. I might even call the whole episode that, Jason.

Suzy: Brilliant. Thank you so much for spending time with us. Take care.

Jason: Okay, thanks, Lucia. Let's catch up again soon.

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